I.

Demographic Data

Name: J.M.A

Address: Sampaloc I, Dasmariñas, Cavite

Age: 4 months old

Gender: Male

Date of Birth: October 04, 2009

Nationality: Filipino

Mother’s Name: J.S.A.

Father’s Name: M.B.A.

Religion: Catholic

Information provided by the mother who is coherent and reliable

II. Reason for seeking health care:

Whenever the parents seek medical care for the child, it is usually due to monthly check-
up.

III. History of Present Illness

The client does not have current illness at the time of assessment.

IV. Past Medical History

A. Pediatric or Childhood Illness

The mother reported that her baby had colds. The mother didn’t say any other
illness aside from colds.

B. Immunization

1
 The child’s immunization status is almost complete except for the measles
vaccine that will be given to him when he becomes nine months in age.

C. Injuries/Accidents

According to the mother of the child, her son has not been injured and had
never been involved in any major accident.

D. Allergies

The mother of the child told that J.M.A. has no known allergies.

E. Medications

The mother told that the child is not taking any medication or supplements as
of now.

F. Hospitalization
A&
According to mother, the child had not been hospitalized and had never gone
A& W
any operation due to illnesses,
W diseases or accidents.
A&W

V. Family Medical History

A& A& A& A& A&

W W W W W
A&W
Genogram A&W A&W A&W A&W

A&
W
A&W

55 y/o 48 y/o 48 y/o 55 y/o

2
 gunshot

41 y/o 39 y/o 36 y/o 33 y/o 31 y/o 27 y/o 34 y/o 31 y/o 24 y/o 22

y/o

10 y/o 6 y/o 4 mos.

Based on the genogram above, on the mother’s side, the grandfather of the child died due
to gunshot at 48 years of age. It is clearly shown that there is no hereditary disease that the client
may acquire from neither of the parents.